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Subchorionic Hematoma

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OBSTETRICAL AND GYNECOLOGICAL SURVEY Vol. 48, No 2
Copyright© 1993 by Williams & Wilkins Printed in U.S. A

Subchorionic Hematoma: A Review

MELISSA PEARLSTONE and LAXMI BAXI
Department of Obstetrics and Gynecology, Sloane Hospital for Women at Columbia Presbyterian Medical Center and The College of
Physicians and Surgeons, Columbia University, New York, New York

A review of the English literature on subchorionic hematoma (SCH) is presented. Fourteen studies
are reviewed. The incidence of SCH varied greatly among studies from 4 to 48 per cent. Small SCH
tend to be more common in the first trimester and appear to pose no added risk to the ongoing
pregnancy. Conversely, SCH in the second trimester often are larger and may be associated with
an increased risk of preterm delivery.
The etiology of these hematomas remains unclear. Pathological changes that might contribute to
their formation are reviewed.
Larger studies with controls, including data on the incidence of SCH in a population of normal
obstetric patients are needed.

Advances in ultrasonographic resolution along
with its increased use in the antepartum period have
led to greater recognition of a number of anatomical
and pathological conditions, included among these
are subchorionic hematoma (SCH). Its presence
raises several issues in patient management and
they have been addressed in this manuscript. Sub-
chorionic hematoma is defined as a sonographically
detected intrauterine echo-free area located be-
tween the membranes and the uterine wall (Fig. 1).
Physiologically, this represents a separation of the
chorionic plate from the underlying decidua with a
resultant collection of blood between the chorion
and decidua. The pathophysiologic basis for this
event remains unclear.
At present, patients with a threatened abortion
and a live fetus as depicted by the presence of fetal
heart rate on ultrasound (US) can expect a 10 per
cent chance of spontaneous abortion in the first
trimester. Those patients who present with bleeding
in the second trimester tend to have a poorer prog-
nosis with an estimated 20 per cent risk of sponta-
neous abortion (2). Many authors have theorized
that out of a population of patients with a threatened
abortion, those with a subchorionic hematoma (SCH)
Reprint requests to: Laxmi Baxi, MD, Dept of Ob/Gyn, Columbia
Presbyterian Medical Center, 622 West 168th Street, New York,
NY 10032.
65
may represent patients at high risk for pregnancy
complications (1,5, 10, 11, 15).
The following constitutes a comprehensive review
of the English literature on the prevalence and clinical
outcome of subchorionic hemorrhage, at times de-
scribed as hematoma on US. Fourteen studies are
included in this review. Information concerning the
incidence of subchorionic hematomas and the clinical
outcome of pregnancies complicated by this phe-
nomenon is presented (Table 1).
In total, 21 papers were reviewed and 14 studies
were selected for detailed analysis. Descriptive pa-
pers, anecdotal accounts, solitary case studies and
papers in which the interpretation of the data was
unclear were excluded. The methodology varied in
different studies and this perhaps explains the dis-
crepancy found in the pregnancy outcomes. In more
than half the studies the patient characteristics are
not addressed, including the presence or absence of
vaginal bleeding. Only five studies included a control
group.
Incidence
The incidence of SCH among patients presenting
with a threatened abortion was quite variable ranging
from a low of 4 per cent to a high of 40 per cent
(4,5, 13, 14, 18,20).
A 4 percent incidence was calculated when only
those cases of SCH with volumes exceeding 50 ml
66 Obstetrical and Gynecological Survey
Fig. 1. Subchorionic hematoma. H, hematoma; P, placenta.
were included (23 of 566) (14). The same authors
described an incidence of 18 per cent when SCH of
all sizes were included (13). In contrast, a near 50
per cent incidence was documented in a population
of patients clearly at high risk for placental abruption.
Six of the original 26 patients, (23 per cent) in that
study had a placental abruption confirmed at delivery
(20). The incidence of SCH in the remaining studies
ranged from 8 to 22 per cent (4,5, 18).
Reviewing the English literature, no information is
available to our knowledge, on the incidence of SCH
as detected by ultrasound in a population of normal
pregnant patients. In 1975, Shanklin and Scott (16)
presented a retrospective study of the pathologic
findings in 19,000 placentas. Ten cases of "massive
subchorial thrombohematoma" were found. These
lesions were defined as "coagulated blood over 1
cm thick separating the villous chorion from the
membranous chorionic plate over much of its area.
Their findings accounted for an overall incidence of
0.53 per thousand deliveries at 25 weeks of gesta-
tion or greater. Information concerning smaller le-
sions and those appearing earlier in pregnancy is not
available.
The only study in which the incidence of SCH at
varying gestational ages is addressed documented
an equal distribution of SCH in both the first and
second trimester (4). Patients presenting in the sec-
ond trimester were more likely to have larger sub-
chorionic hematomas (>30 ml). Stabile et al. (18)
only studied patients in the first trimester and found
an incidence of 8 per cent. Interestingly, the volume
of all subchorionic hematomas in their patient pop-
ulation, was less than 16 ml. These two studies
suggest that SCH in early pregnancy may tend to be
smaller. Perhaps hematomas of larger volume end
in first trimester spontaneous abortions and thereby
go unrecognized.
Pregnancy Outcome
Previous studies have suggested that the risk of
miscarriage in patients with vaginal bleeding after
sonographic demonstration of a living embryo is 10
to 20 per cent (9,19). Of the 14 studies reviewed,
three assessed the pregnancy outcome solely in
patients presenting during the first trimester (3,4, 18).
The rate of spontaneous abortion in these patients
ranged from 0-23 per cent. No preterm deliveries
were documented in this group. The majority of the
patients studied had small hematomas measuring
less than 30 ml.
Two studies reviewed the outcome during the
second trimester (4, 11 ). In these patients, the inci-
dence of spontaneous abortion ranged from O to 11
per cent. The incidence of preterm delivery ranged
from 16 to 25 per cent (4, 11 ), a rate exceeding that
documented in the control groups. These patients
tended to have larger hematomas although the num-
ber studied is small.
If the data is analyzed collectively, the incidence
of spontaneous abortion is 14 per cent (or 40 of 286)
for patients with a threatened abortion, a SCH, and
a live fetus regardless of trimester.
The incidence of preterm deliveries was 12 per
cent overall (or 46 of 385). Goldstein et al. (5) re-
ported no preterm deliveries in their study group.
However, their series included follow-up on only 10
patients presenting between 9 and 16 weeks. Spirit
et al. (17) described four patients with SCH, of which
two (or 50 per cent) went on to deliver preterm. All
of these patients presented in the second or third
trimester.
 Perinatal Outcome: Hematoma 67

TABLE 1 Clinical outcome of pregnancies complicated by SCH

Gestational Control Outcome of pregnancy
Author, Year, age in Study group % with group
(country) (weeks) SCH* (no SCH) Study groupt Control group Comments

Abu-Yousef et al. 8-19 N = 21 None N = 7 (33%) SpAb None Larger SCH as-
(2), 1987, (USA) N = 3 (14%) PTO sociated with
N = 5 (24%) increased risk
Severe bleeding, underwent of poor out-
therapeutic abortion come
Baxi and Pearl- 8-14 N=5 None N = 1 (20%) PTO at 24 Selected group of
stone (2), 1991, weeks neonatal death patients with
(USA) autoantibodies
Block et al. (3), <12 N = 31 None N= 3 (10%) SpAb None Size of SCH not
1989, (USA) ThAb(+)FH N= 2 (6%) PTO related to preg-
N= 26 (84%) FTD nancy outcome
Borlum et al. (4), 8-26 N = 86 (22%) N = 286 N= 19 (22%) SpAb (8.2%) SpAb Volume of SCH
1989, (Denmark) ThAb(+)FH N= 6 (7%) PTO (5.6%) PTO was <30 ml in
85% of the pa-
tients
Goldstein et al. (5), 9-16 N = 10 (20%) N = 40 N = 2 (20%) SpAb (0%) (0%) SpAb Size of SCH not
1983, (USA) ThAb(+)FH PTO (0%) PTO related to preg-
nancy outcome
Jouppila (10), 1985, N = 33 None N = 6 (19%) SpAb None Size of SCH not
(Finland) ThAb(+)FH N = 3 (9.4%) PTO related to preg-
nancy outcome
Mantoni and Peder- 11-20 N = 12 None N = 2 (17%) SpAb None Larger SCH as-
sen (11), 1981, ThAb(+)FH N = 1 (8%) PTO sociated with
(Denmark) increased risk
of poor out-
come
Nyberg et al. (12), N = 46 None N = 3 (6.6%) fetal mortality None Size of SCH not
1987, (USA) N = 6 (12.5%) related to preg-
Termination of pregnancy nancy outcome
N = 12 (25%) PTO
Pedersen and Man- 9-20 N = 62 (18%) N = 280 N = 7 (11%) SpAb N = 28 (10%)
toni (13), 1990, ThAb(+)FH N = 7 (11%) PTO SpAb
(Denmark) N = 32 (11%)
PTO
Pedersen and Man- 6-20 N = 23 (4%) None N = 1 (4%) SpAb Large SCH (>50
toni (14), 1990, ThAb (+) FH N = 2 (9%) PTO ml) not associ-
(Denmark) ated with in-
creased risk of
poor outcome
Sauerbrei and 10-20 N = 30 N = 30 N = 3 (10%) SpAb N = 3 (10%) Large SCH (>60
Pham (15), 1986, N = 4 (13%) stillbirth PTO ml) associated
(Canada) N = 7 (23%) PTO with increased
risk of poor
outcome
Spirit et al. (17), 16-37 N=4 None N = 2 (50%) PTO
1979, (USA) (+)FH N = 2 (50%) FTD
Stabile et al. (18), 9.5-12.1 N = 20 (8%) None 0% SpAb Volume of SCH in
1989, (U.K.) ThAb(+)FH all study pa-
tients < 16 ml
Ylostalo et al. (20), 12-33 N = 16 (62%) N = 10 N = 5 Placental abruption N = 1 Pia- Median duration
1984, (Finland) Includes 2 pts with cental of pregnancy
retroplacental he- abruption shorter in pa-
matoma retropla- tients with a
cental SCH hematoma. (34
vs. 39 weeks)

• SCH, subchorionic hematoma. Per cent with subchorionic hematoma is only listed if this information was obtainable from the study.
t SpAb, spontaneous abortion; PTO, preterm delivery; FTD, full-term delivery; FH, fetal heart; ThAb, threatened abortion.
68 Obstetrical and Gynecological Survey
Conclusion
Spontaneous abortion is a common occurrence in
obstetrical practice. The published literature mainly
refers to SCH as seen in patients with threatened
abortion. It does not address the issue of patients
with additional obstetric or medical problems nor
does it describe its incidental finding on ultrasound.
What then is the clinician to conclude? Which
patients are at risk for developing a subchorionic
hematoma and how does its presence influence the
prognosis of the ongoing pregnancy?
First, the presence of a subchorionic hematoma
does not uniformly imply a poor outcome. Subcho-
rionic hematomas may likely represent an incidental
finding and when small and asymptomatic, are prob-
ably of no clinical significance. Unfortunately, no data
are available documenting the incidence of subcho-
rionic hematomas in an otherwise "normal" obstetric
population. Second, several studies have suggested
that larger hematomas are more likely to be detected
later in pregnancy and may be associated with a
greater risk of preterm delivery (4, 11 ).
The etiology of SCH remains unclear at present.
Subchorionic hematomas have been described in
patients with bleeding disorders both inherited and
iatrogenic. In one case report, a patient with factor
IX deficiency presented with a SCH in late pregnancy
(6). In another patient, a SCH was detected while on
warfarin therapy for a mitral valve replacement (8).
Patients with autoantibodies may also represent a
group at risk (2).
Harris (7) among others has proposed that acute
separation of the placenta is the result of rupture of
the maternal arteriole in the placenta. Vasculopathies
associated with certain disease states such as hy-
pertension may make the placental vessels more
fragile and therefore at greater risk for hemorrhage.
Clearly more prospective studies with controls are
needed to address the etiopathology and natural
course of SCH.
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